Value-based care for CEOs: 4 business and clinical functions for success

Landmark Health | March 16, 2020

Engaging complex patients in value-based care programs can be difficult. But a clear picture of the components of an effective care model and the techniques for attracting patients has emerged.

Proactive, longitudinal models can improve patient experiences by integrating whole patient health care, committing to high standards, and seeking continuous improvement.

Based on a retrospective matched cohort study including 7,729 engaged patients and 10,014 non-engaged patients over a 30-month period, Landmark Health identified two key impacts on medical utilization.

Patients engaged in a longitudinal in-home medical care program had a:

  • 39 percent reduction in emergency room visits
  • 28 percent reduction in hospital admissions

In a separate retrospective cohort study of 36,393 Medicare Advantage patients who were attributed to Landmark Health, the company identified two additional impacts on costs and mortality.

Patients engaged with interdisciplinary, in-home care had a:

  • 20 percent reduction in costs in the last 12 months of life
  • 26 percent lower risk of death

Addressing the needs of an aging population

With the aging U.S. population, value-based care programs are being used to reduce medical costs, improve quality, and ease access to care and resources for vulnerable patients. These complex patients often use urgent care and emergency departments. They are frequently admitted to hospitals or discharged from inpatient to skilled nursing facilities instead of going home. The experience is unpleasant for patients and costly for those holding risk.

In a fee-for-service model, providers see many patients each day to be financially viable. Facility-based providers tend to spend less time with patients, addressing only the most urgent issues. This can lead to confused patients and fragmented care.

The push for payment models that focus on value and outcomes has prompted patient-centric approaches to care. With value-based, in-home medical care, patients have more time with providers and clinical specialists—typically 45 minutes to an hour. Medical concerns can be fully addressed, and care can be coordinated with the patient’s primary care physician and specialists. Successful value-based medical models blend urgent care, 24/7 availability, longitudinal care, and education—the sum of which drives meaningful outcomes.

But how can CEOs lead the move toward value-based care? What follows is a look at the components of a success program, and proven methods for engaging patients in the first place.

Requirements for value-based care of complex patients

A successful value-based program customizes four core business and clinical functions.


  • Recruit local clinical team members drawn to providing care to vulnerable patients.
  • Train providers on working toward value-based metrics.
  • Provide clinical training specific to the patient population.


  • Ensure your electronic medical records system is designed for outcomes-based care.
  • Provide patients with wearable devices, visits by video, and remote monitoring to augment communication between patients and providers.
  • Use a data-driven patient acuity stratification to align resources to need.
    Quantify value of various risk arrangements.


  • Be available 24/7/365 to meet patient needs, including urgent visits.
  • Employ multidisciplinary teams.
  • Quickly implement in markets, including resource allocation, data transfers, education, marketing and outreach.


  • Minimize healthcare costs by reducing unnecessary hospital admissions and emergency department visits.
  • Improve quality ratings through accurate documentation and gap closures.
  • Improve patient satisfaction through convenient access to medical care and care coordination in their home.

Methods to drive patient engagement

By the time you launch your program, you’ll have mastered your member/patient profiles, segmentation and targeting. Yet, you’ll likely struggle to hit 30 percent engagement with your care program. While engagement is challenging, you can reach 50 to 60 percent engagement if you focus on the four clinical and business functions, and execute on a multi-touch patient engagement strategy.

Outreach by telephone starts with your data department. Your outreach team needs to know who to call, in what order. Using data-driven intelligence, a centralized outreach team can more quickly engage patients.

Community-based specialists create awareness and collaboration across the care continuum by meeting with community providers, hospital staff, skilled nursing facility teams, home health agencies, and community-based organizations.

Mail member materials shortly before phone activity begins and create awareness through search and display ads, online content, and a website designed around user journeys.

Caregivers can play a strong role in engaging members, especially among older adults. Caregivers frequently help loved ones make care decisions. Establishing relationships with caregivers can help create strong advocates for your program.


In developing your plan to care for complex patients with value-based medical services, it is important to focus on each of the core elements. Talent acquisition, training and retention, technology and analytics, operations, and aligned incentives are all necessary to help ensure success. In addition, patient engagement requires multiple outreach methods and a data-driven approach.

Value-based care models – when properly executed – can drive improved patient satisfaction and outcomes, reduced costs, and more competitive benefits, helping to fuel growth.

About the Author

Landmark Health, Author

Landmark Health and its affiliated medical groups partner with health plans and delivery systems to bring in-home medical care to complex and chronically ill patients. The company bears risk for more than 100,000 lives across 13 states. Its value-based model relies on physician-led multidisciplinary care teams available to patients 24/7. These fully employed teams help drive long-term outcomes for patients by bringing medical, behavioral, social and palliative care to individuals, where they reside and when they need it.